Stanford emphasized the need to treat patients as people, not cases, but at the same time, our professors would say, this was becoming harder to do because of the way the practice of medicine was changing. Gone were the long-term personal relationships and meaningful encounters, replaced by some newfangled system called “managed care” with its fifteen-minute visits, factory-like treatment, and restrictions on what a doctor could do for each patient. As I moved on from gross anatomy, I thought a lot about what specialty I might choose—was there one in which the older model of the family doctor survived? Or would I not know the names of many of my patients, much less anything about their lives?
I shadowed doctors in various specialties, ruling out the ones with the least amount of patient interaction. (Emergency medicine: exciting, but you rarely see your patients again. Radiology: you see pictures, not people. Anesthesiology: your patients are asleep. Surgery: ditto.) I liked internal medicine and pediatrics, but the physicians I followed warned me that those practices were becoming far less personal—to stay afloat, they had to cram in thirty patients each day. If they were starting out now, a few even said, they might consider another field.
“Why become a doctor if you can write?” one professor asked after he had read something I’d written for a magazine.
When I was at NBC, I worked with stories but wanted real life. Now that I had real life, I wondered if, in the modern daily practice of medicine, there’d be no room for people’s stories. What was satisfying, I discovered, was immersing myself in other people’s lives, and the more I wrote as a journalist, the more I found myself doing just that.
One day, I talked to a professor about my dilemma, and she suggested that I do both—journalism and medicine together. If I could bring in extra income as a writer, she said, I could have a smaller practice and see patients the way doctors used to. But, she added, I’d still have to answer to insurance companies with their time-consuming mounds of paperwork, which would take me away from patient care. Has it really come to this? I thought. Writing as a way to support a living as a doctor? Didn’t it used to be the other way around?
I considered her idea anyway. At that point, though, I was thirty-three years old, with two more years of medical school, at least three years of residency, maybe a fellowship after that—and I knew that I wanted a family. The more I saw the effects of managed care up close, the less I could imagine myself taking the years-long risk of finishing my training and then trying to find out if it was possible to concoct the kind of practice I wanted while also being a writer. Besides, I wasn’t sure I could do both—not well, at least—and also have room for a personal life. By the end of the term, I felt like I had to choose: journalism or medicine.
I chose journalism, and over the next several years, I published books and wrote hundreds of magazine and newspaper stories. Finally, I thought, I’ve found my professional calling.
As for the rest of my life—the family—that, too, would fall into place. At the time I left medical school, I was absolutely sure of it.
15
Hold the Mayo
“Seriously? Is that all you shrinks care about?”
John is back on my couch, sitting cross-legged and barefoot. He’s come in wearing flip-flops because the pedicurist was at the studio today. His toenails, I notice, are as perfect as his teeth.
I’ve just asked something about his childhood, and he’s not happy about it.
“How many times do I have to tell you? I had a great childhood,” he continues. “My parents were saints. Saints!”
Whenever I hear about saintly parents, I get suspicious. It’s not that I’m looking for problems. It’s just that no parent is a saint. Most of us end up being the “good-enough” parents that Donald Winnicott, the influential English pediatrician and child psychiatrist, believed was sufficient to raise a well-adjusted child.
Even so, the poet Philip Larkin put it best: “They fuck you up, your mum and dad, / They may not mean to, but they do.”
It wasn’t until I became a parent that I could truly understand two crucial things about therapy:
The purpose of inquiring about people’s parents isn’t to join them in blaming, judging, or criticizing their parents. In fact, it’s not about their parents at all. It’s solely about understanding how their early experiences inform who they are as adults so that they can separate the past from the present (and not wear psychological clothing that no longer fits).
Most people’s parents did their absolute best, whether that “best” was an A-minus or a D-plus. It’s the rare parent who, however limited, deep down doesn’t want his or her child to have a good life. That doesn’t mean people can’t have feelings about their parents’ limitations (or mental-health challenges). They just need to figure out what to do with them.
Here’s what I know about John so far: He’s forty years old, married for twelve years, and has two daughters, ages ten and four, and a dog. He writes and produces popular television shows, and when I learn which ones, I’m not surprised; he’s won Emmys precisely because his characters are so brilliantly wicked and insensitive. He complains that his wife is depressed (although, as the saying goes, “Before diagnosing people with depression, make sure they’re not surrounded by assholes”), his kids don’t respect him, his colleagues waste his time, and everyone demands too much of him.
His father and two older siblings live in the Midwest, where John grew up; he was the only one to move away. His mother died when he was six and his brothers were twelve and fourteen. She was a drama teacher, and she had been leaving the high school after rehearsal when she saw one of her students in the path of a speeding car. She ran and pushed the student out of the way, but she was hit herself and died at the scene. John told me this part with no emotion, as if he were matter-of-factly recounting the plot of one of his TV shows. His father, an English professor with aspirations to be a writer, took care of the boys alone until he married a widowed neighbor with no children three years later. John described his stepmom as “vanilla, but I have nothing against her.”
While John has had a lot to say about the various idiots in his life, his parents have been largely absent from our conversations. During my internship, a supervisor suggested that with very defended patients, one way to get a sense of their pasts is by asking them, “Without thinking about it, what three adjectives come immediately to mind in relation to your mom’s [or dad’s] personality?” These off-the-cuff answers have always given me (and my patients) helpful insights into their parental relationships.
But nothing comes of this with John. “Saint, saint, and saint—that’s three words for both of them!” he replies, using nouns instead of adjectives despite his writerly facility with words. (I’ll learn later that his father “might have” had a drinking problem after his wife died and “possibly” still does and that John’s oldest brother once told John that their mother “might have” had “a light version of bipolar disorder,” but, John said, his brother was just “being dramatic.”)
I’m curious about John’s childhood because of his narcissism. His self-involvement, defensiveness, demeaning treatment of others, need to dominate the conversation, and sense of entitlement—basically, his being an asshole—all fall under the diagnostic criteria for narcissistic personality disorder. I noticed these traits at our very first session, and while some therapists might have referred John out (narcissistic personalities aren’t considered good candidates for introspective, insight-oriented therapy due to their struggle to see themselves and others clearly), I was game.